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<h3>Section 1: Second Party Information. Answer questions accordingly.</h3>
<hr size="1" width="560" align="left"  color="#993300" />

	<br>Name of Second Party:</br>
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	<br>Address: <br />
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	<br>City, State, Zip: <br />
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	<input  type="text" name="med_2partystate"  value="%%[med_2partystate]%%" size="10" /> 
	<input  type="text" name="med_2partyzip"  value="%%[med_2partyzip]%%" size="10" /> 
			
			
	<br>Phone:<br />
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	<input  type="text" name="med_2partyphone"  value="%%[med_2partyphone]%%" size="31" maxlength="10"/>
			
			
	<br>Cell:<br />
	<input  type="text" name="med_2partymobile"  value="%%[med_2partymobile]%%" size="40" maxlength="18"/>
			
			
	<br>Phone Ref:<br />
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			<hr size="1" width="355" align="left"  color="#993300" /> <br>

	<br> %%[med_2partysenior,yes_no,checkbox]%% Senior 
	%%[med_2partyfamily,yes_no,checkbox]%% Family Member
	%%[med_2partybusinessmerch,yes_no,checkbox]%% Business/Merchant </br>

	<h3>Section 2: Dispute Information</h3>
	
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		Type Of Dispute<br />
       		%%[med_dispute,med_dispute]%%
	
	<br>Primary Mediator<br />
		%%[med_user_id,user_id]%%<br />
		Secondary Mediator<br />
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	<div class="case-notes">
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	Letter to Second party was:
	%%[med_2partysent,yes_no,checkbox]%% Sent 
	%%[med_2partyacknow,yes_no,checkbox]%% Acknowledged

	<h3>Section 3: Outcome </h3>
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        Date Completed <br>
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	<br>Outcome:<br />
		%%[med_outcome,med_outcome]%%

	<br> %%[med_agreeattached,yes_no,checkbox]%% Settlment Agreement Attached ? <br>
	%%[med_outmediaprogram,yes_no,checkbox]%% Mediation was referred to an outside Mediation Program ? <br>
	%%[med_surveysent,yes_no,checkbox]%% Survey has been Sent ? </br>



			
		


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    <input type="hidden" name="case_id" value="%%[case_id]%%"/>
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<input id="save-seniors" class="button" type="submit" value="Save" name="update_case" tabindex="1" accesskey="s" title="Save" onmouseover="this.className='button button-hover'" onmouseout="this.className='button'" />
   
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